Serious and multiple failures at HMP Birmingham probably caused or contributed to a remand prisoner’s suicide

In a detailed narrative conclusion, the jury identified eight areas of failings that probably caused or contributed to Mr Singh’s death by suicide. 
 
The key causative failings identified by the jury included the failure to communicate the repeated concerns raised by Mr Singh’s sisters to relevant staff within the prison over his deteriorating mental health, a failure to use the available interpretation services in order to communicate with Mr Singh in his primary language, a failure to communicate between and within the custodial and healthcare teams, a failure to properly use the Assessment, Care in Custody and Teamwork (ACCT) book process, a lack of rigour in completing prison and healthcare documentation, a failure to carry out adequate welfare checks, a failure to assess Mr Singh for transfer to a secure unit under Section 48 of the Mental Health Act 1983, and a failure to transfer Mr Singh from the general prison wing to an inpatient mental health ward.
 
The jury also found that the failure by the custodial and healthcare teams to heed and communicate the family’s concerns, and the failure to allocate Mr Singh for caseload monitoring by an individual community psychiatric nurse, had possibly caused or contributed to his death.
 
Mr Singh went to prison on 21 September 2021. Just a week after Mr Singh entered prison, his sisters began raising concerns to the prison’s Safer Custody team that he was suffering from hallucinations and suicidal thoughts. His sisters continued to raise serious concerns about Mr Singh’s deteriorating mental state and suicidal ideation to Safer Custody throughout his imprisonment. This included urgent pleas for Mr Singh to receive mental health treatment and to be transferred to a mental health hospital. However, these concerns were only communicated to the custodial and healthcare teams on a piecemeal and limited basis. Most of the clinicians and custodial staff directly involved in Mr Singh’s care were not aware of the correspondence or its content. 
 
On 3 December 2021, Mr Singh was assessed by an Independent Consultant Psychiatrist who concluded that he was suffering from serious psychotic features and required inpatient mental health treatment. The psychiatrist assessed Mr Singh as unfit to plead or stand trial and referred him to a medium secure psychiatric unit. However, owing to a series of failures in communication, Mr Singh was not further assessed for s.48 transfer by either the prison mental health team or the external mental health unit. Mr Singh was therefore never transferred for treatment within a secure psychiatric setting.
 
On 14 January 2022 Mr Singh was assessed by another Independent Consultant Psychiatrist who also concluded that he was unfit to plead and required hospital transfer.  On the same day, he was assessed by the visiting prison Consultant Psychiatrist, who concluded that he required urgent admission to the prison’s inpatient mental health ward. Again, despite the Psychiatrist’s referral to the prison mental health inpatient ward, this requested admission never took place. The clinical staff directly involved in Mr Singh’s care were not made aware of the fact or rationale for this refusal.
 
On 27 January 2022, Mr Singh was found unconscious in his cell at HMP Birmingham and was rushed to hospital, where he died in the early hours of 28 January 2022.
 
At the conclusion of the inquest Area Coroner Emma Brown confirmed that she would be issuing a Prevention of Future Deaths report to the mental health provider at the prison in respect of two areas she considered continued to pose an ongoing risk to the lives of others.
 
The first was to involve prison Psychiatrists in the multi-disciplinary team meetings that co-ordinate mental health provision for prisoners on their caseload. The second was to consider inclusion of a running risk assessment document in the medical records of prisoners with mental health concerns, equivalent to the template often used in the context of community and inpatient mental health provision. 
 
In a statement Mr Singh’s sisters said:

“Jai was kind and caring. Without him our world seems empty, and we cannot explain the pain of losing him. Jai was badly let down by the systems which should have protected him, and we want to make sure that no one else goes through what Jai did.”
 
Leigh Day solicitor Maya Grantham represents Mr Singh’s sisters. She said:

“Despite every psychiatrist who assessed Mr Singh concluding that he required inpatient mental health treatment, and despite his sisters’ repeated pleas for him to receive urgent help, he was left in the general population of the prison without the care and treatment he needed. The jury’s wide-ranging findings demonstrate that the systems in place to protect people like Mr Singh failed him again and again.”